Ethical Vignettes in Reproductive Health

Document Sample
Ethical Vignettes in Reproductive Health Powered By Docstoc
					Page 1 of 18
                                               Page 2 of 18


                            By Naira R. Matevosyan, MD, PhD
                           Copyright © 2011-2016 Naira R. Matevosyan

SUMMARY: Present meta-study elucidates country-based ethical priorities in reproductive health. A
total of 96 sources published in 1986-2011, and suitable for level of evidence (I-IIA), are identified
through PubMed portal. Pooled prevalence of bioethical problems, their determinants, and outcomes
are modeled as measurable outcomes. Ethical debates are correlated with extrapolated maternal and
perinatal mortality rates from salient obstetrical data. Results suggest that ethical principles are not
equally discussed (Cochran's Q 65.08). 50% of studies present two or more ethical debates.
Beneficence and nonmaleficence are strongly associated (Pearson's chi 56.12, p < 0.002). Correlations
fail to display associations between ethical issues, and country-based perinatal mortality rates (0.117 -
0.209). Patient`s autonomy, adolescent's pregnancy, fetal surgery, cross-boarder reproduction,
surrogacy, stem cell registry, and reproductive health in mentally ill, remain poorly seen or addressed
ethical debates in reproductive health.

KEYWORDS: Maternal-fetal conflicts, In-vitro fertilization, Posthumous reproduction, Stem cell
research and registry


                   I.     Problem Definition                         Page 3

                   II.    Methods                                    Page 5

                   III.   Data Extraction & Analysis                 Page 6

                   IV.    Results                                    Page 6

                   V.      Discussions                               Page 11

                   VI.     Conclusions                               Page 13

                   VII.    Implications for Research                 Page 13

                   VIII. Works Cited                                 Page 14
                                               Page 3 of 18

       I. PROBLEM DEFINITION: Reproductive health providers commonly confront complex

ethical questions that can be answered only through thoughtful consideration of values, interests, rights,

and obligations of those involved [1]. Providers struggle daily with tough decisions that arise in serving

previable patient, adolescents, counseling HIV-positive clients and victims of domestic violence. No

society, no culture, no religion, and no statutory or case law has been neutral about ethical issues of

human reproduction and maternal-fetal conflicts. While ethical principles cannot dictate solutions to

problems that arise from a genuine lack of resources, they do indicate solutions to preventable

problems. Such universal ethical principles include the principle of beneficence, which obligates people

to attempt to produce more good than harm.

       Universal ethical principles can be used to analyze problems in reproductive health. The

principle of beneficence obligates people to strive to bring about more beneficial consequences than

harmful ones. The principle known as respect for persons presumes that all human beings have dignity

and are worthy of respect. Showing equal respect for the pregnant woman and fetus as persons, means

recognizing their autonomy and treating them as capable decision-makers and full participants in

medical decisions. Another leading concern of bioethics is justice, which requires egalitarian

performance by the provider, and libertarian thinking by the patient. Statutory and case laws, policies,

and practices must be changed if they result in consequences more harmful than helpful.

       Ethical principles of public health are distinguishable from principles applied in modern

bioethics. At the risk of over-simplifying the difference between clinical ethics and public health ethics,

it could be said that the default position of clinical ethics centers on respect for the individual patient

and his/her autonomy, whereas the default position of public health ethics centers on the pursuit of the

collective or common good. By its very nature, public health aims first and foremost at promoting

population benefit and thus has a broadly 'utilitarian' orientation, which tends to place emphasis on
                                                Page 4 of 18

maximizing overall 'output,' rather than to focus upon 'gain/lose' ratio at the level of the individual.

While public health ethical aspects of human reproduction concern reduction of unsafe abortion,

maternal mortality and morbidity most prevalent where abortion laws are restrictive [22, 24], bioethical

principles are developed at the clinical or microethical level affecting relations among individuals,

whereas pubic health ethics applies at population-based, macroethical level. Public health

recommendations are mostly derived from inter-disciplinary commissions that solicited public input in

that particular country or region [15]. For instance, the World Health Organization (WHO) defines

sterility as an illness, but a wast number of countries do not accept this definition [45].

       The role of biotheology is foremost to clarify for different religious communities perceived

attitudes toward these developments. Judaism and Islam allow the practice of assisted reproduction

when the oocyte and sperm originate from the wife and husband, respectably. The practice of assisted

reproduction is not accepted by the Vatican, but is allowed by Protestant, Anglican, Lutheran, and

other Denominations. All Rabbinical rulings permit the use of contraception for medical indications.

Judaism forbids abortion on demand but allows therapeutic abortion. The Christian tradition views the

embryo as a human being since conception and therefore, abortion and contraception are strictly

forbidden [76]. Equilibrium can be best achieved by nurturing interdependent relationships that

empower and protect the vulnerable women, including those with mental illnesses [26].

       Women with serious mental illnesses, or illicit substance users, may be unable to understand

and consent for reproductive health interventions. Evidence suggests that women with schizophrenia

and mood disorders have reduced fertility, more lifetime sexual partners, high rates of unwanted

pregnancies, fewer planned pregnancies and live births, severe parenting difficulties, and are at

significantly enhanced risk for HIV infection [57]. About 50% of mentally ill women are sexually

active, and 43% among the moderately retarded women become pregnant. The intellectual impairment
                                                    Page 5 of 18

and stigma among mentally ill prolong and challenge their gynecological counseling and examination.

        Practitioners often confront the question whether or not they have to employ the method of

advanced decisions by the third party in management of reproductive health issues in mentally ill

patients. However, in many cases the concept of the 'reproductive health' is being misunderstood.

Human reproduction cannot be viewed exclusively in its primordial goal, e.g. the perpetuation of the

species [27]. The WHO defines reproductive health as as a state of physical, mental, and social well-

being in all matters relating to the reproductive system at all stages of life. Implicit in this are the rights

of men and women to be informed and to have access to safe, effective, affordable, and acceptable

methods of family planning of their choice. Current study prioritizes major ethical debates in

reproductive health; surpasses ethical pluralism; and celebrates studies that are less focused on debates

and more focused on practical resolutions.

        II. METHODS: Ninety-six studies published in 1986-2011 are identified through PubMed and

are inclusive for relevance and level of evidence (I, II-1). Key monographs are hand-searched. There is

no restriction on language of studies. Pooled prevalence of ethical problems (patient's autonomy,

maternal-fetal conflicts, stem cell research, disclosure decisions, others), their approximate

determinants (health policy, religious constraints, infrastructure conflicts), and outcomes (maternal,

fetal, infant, and perinatal morbidity and mortality) are modeled as measurable outcomes. Current

evaluation covers a number of contradictions: abortion [7, 85, 94], maternal autonomy [6, 8, 11, 25, 32, 46,

60, 69], maternal-fetal conflicts, elective fetal surgery [54, 58], rights of previable/viable intrauterine

patient [14, 17], adolescents` pregnancy [5], disclosure decisions [35], emergency contraception [16],

reproductive technologies [65, 68, 74, 86, 90], in vitro fertilization [33, 38, 72], human enhancement

technologies [6], oocyte donation [52, 80], surrogacy [22, 67, 78, 81], gene therapy [93], stem cell research

and registry [39, 43, 47, 61, 62, 68, 71, 84], religion [28, 34, 75, 88], and public health ethics [2, 30, 67].
                                                 Page 6 of 18

       III. DATA ANALYSIS: Data are extracted for the associations between ethical principles and

clinical outcomes. Kruskal-Wallis analysis of variance (ANOVA) is used for the ranked ordinal data;

Chi-squared (X2) is used where data are categorical with a 95% confidence interval (CI) using a fixed

effects model. Generalized estimating equations are used with an exchangeable correlation structure

into which a Pearson model is fitted. Chronbach`s alpha is computed for the interclass construct

validity. Factors with intraclass-correlation (ICC) coefficient above 0.400 are considered as

comparative. Pooled estimates of ethical issues and practices per country are correlated with country-

based perinatal and maternal mortality rates extrapolated from salient obtstetrical data. Analyses are

performed using ASSISTAT (version 7.5 β, 2008) and EpiInfo (version 3.5.1).

       IV. RESULTS:        The U.S. researchers contribute in 60.4% of studies (n=58). Twenty two

studies are from Europe (n=22), in particular, from Belgium [61, 69, 70], Denmark [49], Finland [36, 65],

France [52, 68], Germany [43, 45], Ireland [58, 80], Poland [19], Romania [27], Spain [33], and the U.K [12,

25, 40, 59, 78, 85, 90]. Eleven studies are conducted in Canada (n=11) [10, 16-18, 21-24, 44, 76, 93] and nine

in Australia [64], Chile [76], Iran [95], Israel [71, 76], Japan [83, 87], Kenya [49], and Turkey [74]: (n=9).

Table 1 presents country-based ethical debates:

             Table 1: Country-based ditribution of ethical debates in reproductive health

Problem:                             U.S.A                Canada               U.K & EU        Oceania , Asia
                                                                                               & Elsewhere

Adolescent's pregnancy      Aruda (2008)                        -                    -               -

Autonomy                    Athar (2008) Balint      Cook (2009)            Pennings (2007)   Su (2005)
                            (2002) Bergeron (2007)   Seavilleklein (2009)
                            Donchin (2009)           Woodcock (2010)
                            Dudzinski (2006)
                            Goering (2009) Kukla
                            (2009) McLeod (2009)
Cloning                     Fiester (2005)                      -           Niemelä (2010)    Revel (2003)
                                                                            Pellerin (2002)
Client and provider         Balint (2005)            Cook (2002, 2006,               -               -
education in bioethics      Hill (1987)              2009)
                                                      Page 7 of 18

Disclosure decisions           Aruda (2008)                          -               -                  -
                               Hahn (2002)
Elective abortion              Adams (2002) Ballantyne Cook (2002, 2006,    McDonnell (2006)    Samtani (2009)
                               (2009) Clune (2009) Hill 2009) Dickens       Timpson (1996)      Zahedi (2008)
                               (1987) Walters (1986)    (2007) Woodcock
Emergency contraception                      -            Cook (2006)                -                  -
Fetal surgery                  Lyerly (2001, 2007)                   -               -                  -
Gene therapy                   Park (2009) Wolf (2009)               -               -                  -
Informed clinical trials and Macklin (1995)               Woodcock (2010)   Czarkowski (2009)   Lema (2009)
consents                                                                    Lebech (1997)

In vitro fertilization (IVF)   Hill (1987)                Baylis (2003)     Dumitrache (1993)   Schenker (2000)
                               Rosenthal (2010)                             Gracia (1988)
                                                                            Niemelä (2010)
                                                                            Pellerin (2002)
                                                                            Pennings (2007)
Health insurance               Hall (2009)                           -               -                  -
Human enhancement              Athar (2008)               Krahn (2009)      Bostrom (2005)              -
technologies                   Park (2009)

Malpractice                    Davis (1997)               Cook (2009)                -                  -
                               Jones (1996)
                               Lyerly (2007)
Medicalization of              Bergeron (2007)                       -               -                  -
Oocyte donation                              -                       -      Letur-Könirsch      Zahedi (2008)
                                                                            (2004) Sills (2008)
Procreative liberty            Cohen (1997)                          -      Pennings (2007)             -
                               Steinbock (1995)
Public health ethics           Agarwal (2007)           Dickens (2007)               -                  -
                               Anonymous (2000) Evans
                               (1993) Pellegrino (1987)
Religion                       Eberl (2009) Habgood                  -      McDonnell (2006)    Schenker (2000)
                               (1985)                                                           Ueda (2008)
                                                                                                Samtani (2009)
Reproductive health in         Dudzinski (2006)                      -               -
mentally ill or disabled       Lyerly (2001)                                                    Newell (2006)
                               Matevosyan (2009)
Rights of intrauterine         Ballantyne (2009)          Cook (2009)                -                  -
patient                        Clune (2009)               Dickens (2008)

Reproductive technologies Evans (1993) Turner             Baylis (2003)     McDonnell (2006)    Sahinoglu-Pelin
                               (2009)                     Dickens (2008)    Niemelä (2010)      (2002)
                                                                            Pellerin (2002)
                                                    Page 8 of 18

                                                                         Pennings (2007)
                                                                         Warnock (1987)
Surrogacy                     Hill (1987) Pellegrino    Dickens (2008)   Shenfield (2005)           -
                              (1987) Steinbock (1995)                    Sills (2008)
Stem cell research and        Balint (2002) ISCBI                  -     Kress (2006) Mertes Revel (2003)
registry                      (2009) Hyun (2010)                         (2009) Pellerin
                              Latham (2009, 2009)                        (2002)
                              Meyer (2009) Taymor
Total research contribution   58 (47.5%)                22 (18.0%)       29 (23.7%):         13 (10.6%)
per country/ region:

       The number of studies included in Table 1 (n = 122) exceeds total number of reviewed studies

(n=96), as the majority of studies present more than one ethical debates. It can be seen that patient`s

autonomy (10.9%), elective abortion (11.7%), IVF (7.5%), and stem cell research (9.2%) remain the

major themes (95% CI, p<0.05). Adolescent pregnancy (0.8 %), emergency contraception (0.8%), fetal

surgery (1.7%), oocyte donation (2.5%), gene therapy (1.7%), human enhancement techniques (3.3%),

health insurance limitations (0.8%), malpractice (3.3%), medicalization of childbirth (0.8%), and

reproductive health in mentally ill or disabled (3.3%) are the least attended ethical issues in

reproductive medicine. The proportions of each ethical principle are tested against each other for

equality using Cochran's Q test; the Q test reaches statistical significance (65.08, df = 3, p < 0.0001)

indicating that the ethical principles are not equally discussed. Current review locates scant data on

cross-boarder reproductive care, and no data on maternal-fetal conflicts, pregnancy in terminally ill

patients, and advanced decisions for mentally ill.

       As shown in Table 1, the U.S and Canadian studies mostly capture ethical debates related to

patient`s autonomy (13.7%), abortion (12.5%), client and provider education (6.25%), malpractice

(5.0%), public health ethics (6.2%), and stem cell research and registry (8.7%), whereas the European

studies are more focused on reproductive technologies (17.2%), IVF (17.2%), oocyte donation (6.9%),
                                                 Page 9 of 18

surrogacy (10.3%), and stem cell research (10.3%). When examining both major and minor themes,

forty eight articles (50%) present two or more ethical principles. Beneficence and nonmaleficence are

strongly associated (Pearson's chi 56.12, df = 1, p < 0.002). Of the total abortion debates, 66.7% are pro-

choice (p< 0.015) [7, 14, 18, 24, 38, 58, 85, 89, 94, 96], 6.7% pro-life (p< 0.058)[75], and 26.7% pro-middle

(p< 0.02) [1, 16, 17, 83]. Seven studies discuss theological debates, of which two (28.5%) are related to

Catholicism [28, 34], two (28.5%) Judaism [28, 76], one (14.3%) Islam [95], one (14.3%) Hinduism [75],

and one (14.3%) Buddhism [87].

           Studies suggest on 17-22% pregnancy rates from transferred frozen-thawed embryos [France],

86%- after infertility treatment, 26% - from the cross-boarder fertility treatment [UK], 1.9%- from the

cryopreserved empryos allocated for research [Canada], 60% consent for posthumous reproduction

[Japan],   and 47% consent for fetal surgeries for nonlethal reasons [USA]. 77% of studies support that

innovative therapies, such as fetal surgeries, should be performed only under IRB-approved protocols

and 55.2 % indicate that these procedures have not been validated [USA]. 48.2% pregnant adolescents

opt to continue their pregnancy, 45% choose to terminate, and 6% have miscarriages. Adolescents who

continue their pregnancy have a significantly longer time interval to their referral site, averaging 24

days until a prenatal appointment, compared to 17 days for a termination [USA].

           Overall, studies are not informative enough on how and when ethical issues arise, do not assess

the epidemiological risk factors for ethical and legal problems that emerge in reproductive health, and

the role of parties inolved. Furthermore, the qualitative and quantitative ethical goals vary in different

countries and regions. Secular trends in ethics are difficult to interpret because of diverse social and

ethnic structure of the target countries. Therefore, current study presents country-based ethical

priorities. Figure 1 illustrates proportional weights of country-based major ethical debates:
                                                Page 10 of 18

            Figure 1: Country -based distribution of ethical debates in reproductive health

         Pooled estimates of country-based ethical debates are extracted for further correlations with

extrapolated perinatal and maternal mortality ratios from obstetrical reports of various countries, as

presented in Table 2:

                             Table 2: Maternal/ perinatal mortality ratios

Country: Proportional weight      Maternal mortality *          Lifetime risk of    Perinatal mortality**
          of countries in the                                   maternal death*
               sample:            Incidence per 100,000         One incidence in:   Incidence per 1,000 live
                 n (%)                  live births                                          births
Australia         1 (1.03)                 4                        13,.300                   4.4
Belgium           3 (3.09)                 8                         7,.800                   4.2
Canada           11 (11.3)                 7                        11,.300                   4.8
Chile             1 (1.03)                 16                        3,.200                   7.2
Denmark           1 (1.03)                 3                        17,.800                   4.4
Finland           2 (2.06)                 7                         8,.500                   3.7
France            2 (2.06)                 8                         6,.900                   4.2
Germany           2 (2.06)                 4                        19, 200                   4.3
                                                   Page 11 of 18

Iran                1 (1.03)                 140                     300                       30.6
Ireland             2 (2.06)                  1                     47, 600                    4.9
Israel              2 (2.06)                  4                     7,.800                     4.7
Japan               2 (2.06)                  6                     11, 600                    3.2
Kenya               1 (1.03)                 560                      39                       64.4
Poland              1 (1.03)                  8                     10, 600                    6.7
Romania             1 (1.03)                  24                    3, 200                     14.9
Spain               1 (1.03)                  4                     16, 400                    4.2
Turkey              1 (1.03)                  44                     880                       27.5
UK                  7 (7.21)                  8                     8, 200                     4.8
USA                55 (56.7)                  11                    4, 800                     6.3
 Sources: * Monitoring the situation of children and women: UNICEF report, 2005
          ** Unite for children: UNICEF report, 2008

          As shown in Table 2 Kenya and Iran have the highest maternal and perinatal mortality ratios

and lifetime risk of maternal death. Ireland, Spain, Australia, and Japan report the lowest maternal and

perinatal mortality risks and ratios. Pearson correlations reveal non-significant associations between

ethical vignettes discussed in current review and maternal and perinatal mortality estimates: r2 = 0.138,

0.209, and 0.117, correspondingly. Correlations fail due to the small sample-size, and the abscence of

existing knowledge and reports on causes and conditions of each ethical dilemma that could be used as

an intervening variable of interest.

          V. DISCUSSIONS: Ethical problems (abortions, autonomy, IVF, stem cell research, disclosure

decisions), their approximate determinants (religious constraints, infrastructure conflicts), and

outcomes (maternal and perinatal mortality rates) presented in 96 studies published between 1986 and

2011, are modeled as measurable outcomes. Ethical debates are correlated with country-based maternal

and perinatal mortality rates through applying the Pearson method.

          Secular trends in maternal-infant health ethics are difficult to interpret because of diverse social,

and ethnic profile of target groups. The strength of these associations is small compared with impact of
                                                 Page 12 of 18

public health policies that vary in each country. 90.6% of studies present debates without practical

solutions. Human enhancement techniques, assisted and posthumous reproduction raise an immense

number of questions regarding the quality of health and life of the child born under these

circumstances. Patient's autonomy, adolescent's pregnancy, fetal surgery for nonlethal reasons, mental

and somatic health of child derived by human enhancement techniques, posthumous dignity, cross-

boarder reproduction, health insurance for assisted reproduction, medicalization of childbirth, stem cell

registry, and reproductive health in mentally ill remain the least attended ethical topics in reproductive


          Correlations fail to find associations between presented ethical issues and country-based

maternal and perinatal mortality rates ( r2 = 0.117- 0.209). Current study defines and classifies

maternal-fetal conflicts:

          (I) Behavioral (vegetarian or low calorie diet in pregnancy, smoking, informed assent);

          (II) Psychosocial (serious mental illness, illicit drug use, smoking, alcoholism);

          (III) Environmental (exposure to hazards, vibration, noise, heavy metals, and bio-substances);
          (IV) Obstetrical (placentation defects);

          (V) Medical (preexisting medical conditions, sych as diabetes mellitus, hypertension, thyroid
dysfunction, cancer, lupus, vertically transmitted infections);

          (VI) Biological (Rhesus and LHA conflicts);

          (VII) Iatrogenic (diagnostic errors and malpractice);

          (VIII) Paternal (unwished pregnancy, financial instability, poor relationships and attachment);
          (IX) Legal (conflicts between infrastructures, such as the Supreme Court and State Laws);
          (X) Public health (conflicts between Committee Statements, such as American Academy of
Pediatrics, American College of Obstetricians and Gynecologists).

          Present review suggests that clinical pregnancy rate from the transferred frozen-thawed

embryos reaches 17-22%; 1.9% of cryopreserved empryos are allocated for research; 60% of couples
                                                Page 13 of 18

consent for posthumous reproduction; 47% consent for fetal surgeries for nonlethal conditions; 48.2%

pregnant adolescents choose to continue their pregnancy, 45% opt to terminate, and 6% have


          Limitations: This study cannot afford enabling factor-outcome flotations: for instance, abortion

could be both cause and consequence of an ethical conflict. Next, there may be discrepancies in

definitions of perinatal morbidity in studies published prior and after the U.S. committee on Fetus and

Newborn updates on fetal viability threshold (from 28th to 22nd gestational weeks). This limitation is

addressed through utilizing obstetrical data published after the policy update (1995).

          Study strength: The vigor of this study is firstly and mostly in its multi-dimensional, and

country-based assessments of ethical debates and priorities. It also classifies maternal-fetal conflicts.

          VI. CONCLUSIONS: Patient's autonomy, adolescent's pregnancy, fetal surgery for nonlethal

reasons, posthumous dignity, cross-boarder reproduction, stem cell registry, and reproductive health in

mentally ill are the least attended ethical issues in reproductive health. Correlations fail to display

asociations between country-based ethical problems and maternal and perinatal mortality rates (r2 = 0.117-

0.209). Ethical principles are not equally discussed (Cochran's Q 65.08). 66.7% of abortion debates present

pro-choice, 6.7% pro-life, and 26.7% - balanced positions. 50% of studies present two or more ethical

principles. Beneficence and nonmaleficence are strongly associated (Pearson's chi 56.12, df = 1, p <


          VII. IMPLICATIONS FOR RESEARCH: What is new in reproductive health ethics? A lot, but

not enough. An essential element of a good reproductive health study, or service delivery is that it be

performed in an ethical manner. In other words, ethics in medical practice and research operates as a

gatekeeper between what is legal, and what is not. Admitting and understaning ethical codes by both

patient and provider, may reduce        court-visited and ordered medical interventions. Unfortunatly,
                                                 Page 14 of 18

important barriers still remain in translating peculiar circumstances into meaningful improvement of

our understanding in reproductive health ethics. Further research should feature each ethical debate

with detailed observations of personal (ethnicity, education, marital and economic status), contextual

(public policy, health insurance limitations, cross-boarder health), and clinical (preexisting somatic/

mental conditions, genetic susceptibility, subject`s consentability and judgemental fit) factors that

contribute in ethical conflicts.


    1. Adams KE (2002). Ethical issues in gynecology: adolescent confidentiality, provider conscience and
        abortion, and patient choice of provider gender. Current Women's Health Report; 2(6):423-8
    2. Agarwal SK, Estrada S, Foster WG, et al (2007). What motivates women to take part in clinical and
        basic science endometriosis research? Bioethics; 21(5):263-9
    3. Anonymous (2006). NIH State-of-the-Science Conference Statement on cesarean delivery on maternal
        request. NIH Consens State Sci Statements; 23(1):1-29
    4. Anonymous (2000). The Declaration of Monaco. Bulletin of Medical Ethics; (157):11
    5. Aruda MM, McCabe M, Litty C, et al (2008). Adolescent pregnancy diagnosis and outcomes: a six-
        year clinical sample. Journal of Pediatrics and Adolescent Gynecology; 21(1):17-9
    6. Athar S (2008). Enhancement technologies and the person: an Islamic view. Journal of Law, Medicine
        and Ethics; 36(1):59-64, 3
    7. Ballantyne A, Newson A, Luna F, et al (2009). Prenatal diagnosis and abortion for congenital
        abnormalities: is it ethical to provide one without the other? American Journal of Bioethics; 9(8):48-56
    8. Balint JA (2002). Ethical issues in stem cell research. Albany Law Review; 65(3):729-42.
    9. Balint JA (2005). A caring partnership: can we gain control? The Mount Sinai Journal of Medicine;
    10. Baylis F, Beagan B, Johnston J, et al (2003). Cryopreserved human embryos in Canada and their
        availability for research. Journal of Obstetrics and Gynecology Canada; 25(12):1026-31
    11. Bergeron V(2007). The ethics of cesarean section on maternal request: a feminist critique of the
        American College of Obstetricians and Gynecologists' position on patient-choice surgery. Bioethics;
    12. Bostrom N (2005). In defense of posthuman dignity. Bioethics; 19(3):202-14
    13. Camby C (2008). The French Biomedicine Agency and medically assisted reproduction. Bulletin de
        l`Academie Nationale de Medecine; 192(1):17-21; discussion 21-2
    14. Clune A (2011). Deeper problems for Noonan`s probability argument against abortion: On a charitable
        reading of Noonan`s conception criterion of humanity. Bioethics; 25/5: 280-289
    15. Cohen CB (1997). Unmanaged care: the need to regulate new reproductive technologies in the United
                                             Page 15 of 18

    States. Bioethics; 11(3-4):348-65
16. Cook RJ, Dickens BM, Erdman JN. (2006). Emergency contraception, abortion and evidence-based
    law. International Journal of Gynecology and Obstetrics; 93(2):191-7
17. Cook RJ, Dickens BM (2009). From reproductive choice to reproductive justice. International Journal
    of Gynecology and Obstetrics; 106(2):106-9
18. Cook RJ, Dickens BM. (2002). Human rights and HIV-positive women. International Journal of
    Gynecology and Obstetrics; 77(1):55-63
19. Czarkowski M (2009). Guidelines on research on human biological materials. Polski Merkuriusz
    Lekarski; 27(160):349-52
20. Davis DS (1997). Legal trends in bioethics. Journal of Clinical Ethics; 8(4):405-10.
21. Dickens BM, Cook RJ. (2006). Conflict of interest: legal and ethical aspects. International Journal of
    Gynecology and Obstetrics; 92(2):192-7
22. Dickens BM (2008). Legal developments in assisted reproduction. International Journal of Gynecology
    and Obstetrics; 101(2):211-5
23. Dickens BM, Cook RJ (2008). Multiple pregnancy: legal and ethical issues. International Journal of
    Gynecology and Obstetrics; 103(3):270-4
24. Dickens BM, Cook RJ (2007). Reproductive health and public health ethics. International Journal of
    Gynecology and Obstetrics; 99(1):75-9
25. Donchin A (2009). Toward a gender-sensitive assisted reproduction policy. Bioethics; 23(1):28-38
26. Dudzinski DM (2006). Compounding vulnerability: pregnancy and schizophrenia. American Journal of
    Bioethics; 6(2):W1-14
27. Dumitrache C, Drăghia R (1993). Alternatives in human reproduction. Methods, indications,
    prognosis, bioethical problems. Roman Journal of Endocrinology; 31(1-2):5-22
28. Eberl JT (2009). The complex nature of Jewish and Catholic bioethics. American Journal of Bioethics;
29. Edwards RG, Benagiano G, Dahl E (2009). Ethics, law and moral philosophy of reproductive
    biomedicine. Foreword. Reproductive Biomedicine Online; 18 Suppl 1:5
30. Evans JR.(1993). International challenges and opportunities in health. Journal of Law, Medicine and
    Ethics; 21(1):10-5
31. Fiester A (2005). Ethical issues in animal cloning. Perspectives in Biology and Medicine; 48(3):328-43
32. Goering S (2009). Postnatal reproductive autonomy: promoting relational autonomy and self-trust in
    new parents. Bioethics; 23(1):9-19
33. Gracia D (1988). Spain: new problems, new books. The Hastings Center Report; 18(4):S29-30
34. Habgood JS (1985). Medical ethics--a Christian view. Journal of Medical Ethics;11(1):12-3
35. Hahn SJ, Craft-Rosenberg M (2002). The disclosure decisions of parents who conceive children using
    donor eggs. Journal of Obstetrics, Gynecology, and Neonatal Nursing; 31(3):283-93
36. Halila R (2003). The role of national ethics commissions in Finland. Bioethics;17(4):357-68
37. Hall MA, Schneider CE (2009). Professional obligations when patients pay out of pocket. The Journal
                                             Page 16 of 18

    of Family Practice; 58(11):E1-E4
38. Hill EC (1987). Obstetrics and gynecology. JAMA; 258(16):2276-7
39. Hyun I (2010). The bioethics of stem cell research and therapy. The Journal of Clinical Investigation;
40. International Stem Cell Banking Initiative (2009). Consensus guidance for banking and supply of
    human embryonic stem cell lines for research purposes. Stem Cell Reviews; 5(4):301-14
41. Johnson MH (2002). The art of regulation and the regulation of ART: the impact of regulation on
    research and clinical practice. The Journal of Law, Medicine & Ethics; 9(4):399-413
42. Jones TR (1996). Speak no evil: physician silence in the face of professional impropriety. JAMA;
43. Kress H. (2006). Health protection and embryo protection from an ethical-legal perspective. Report of
    the Bioethics Committee of Rheinland-Pfalz on the need to revise the embryo protection and stem cell
    laws. Ethik Medicine; 18(1):92-9
44. Krahn T (2009). Preimplantation genetic diagnosis: does age of onset matter (anymore)? Medicine,
    Health Care and Philosophy; 12(2):187-202
45. Krones T, Neuwohner E, El Ansari S, et al (2006). Desire for a child and desired children--
    possibilities and limits of reproductive biomedicine. Ethik Medicine; 18(1):51-62
46. Kukla R, Kuppermann M, Little M, et al (2009). Finding autonomy in birth. Bioethics; 23(1):1-8
47. Latham SR (2009). Between public opinion and public policy: human embryonic stem-cell research
    and path-dependency. The Journal of Law, Medicine & Ethics; 37(4):800-6
48. Latham SR (2009). The once and future debate on human embryonic stem cell research. Yale Journal of
    Health Policy Law and Ethics; 9 Suppl:483-94
49. Lebech AM (1997). Anonymity and informed consent in artificial procreation: a report from Denmark.
    Bioethics; 11(3-4):336-40
50. Lema VM, Mbondo M, Kamau EM (2009). Informed consent for clinical trials: a review. East African
    Medical Journal; 86(3):133-42
51. Leonir N (1993). French, European, and international legislation on bioethics. Suffolk University Law
    School: Law Review; 27(4):1249-70
52. Letur-Könirsch H (2004). Oocyte donation in France and national balance sheet (GEDO). Different
    European approaches. Gynecology, Obstetrics, and Fertility; 32(2):108-15
53. Long SA (2000). A conflict of interest in reproductive medicine. Ethics & Medicine;16(2):54-7
54. Lyerly AD, Cefalo RC, Socol M, et al (2001). Attitudes of maternal-fetal specialists concerning
    maternal-fetal surgery. American Journal of Obstetrics and Gynecology; 185(5):1052-8
55. Lyerly AD, Mitchell LM, Armstrong EM, et al (2007). Risks, values, and decision making
    surrounding pregnancy. Obstetrics and Gynecology; 109(4):979-84
56. Macklin R (1995). Ethics, informed consent, and assisted reproduction. Journal of Assisted
    Reproduction; 12(8):484-90
57. Matevosyan NR (2009). Reproductive health in women with serious mental illnesses. Sexuality and
    Disability; 27(2): 109-118
                                             Page 17 of 18

58. McDonnell O, Allison J. (2006). From biopolitics to bioethics: church, state, medicine and assisted
    reproductive technology in Ireland. Sociology of Health and Illness; 28(6):817-37
59. McKelve A, David AL, Shenfield F, et al (2009). The impact of cross-border reproductive care or
    'fertility tourism' on NHS maternity services. BJOG: An International Journal of Obstetrics and
60. McLeod C (2009). Rich discussion about reproductive autonomy. Bioethics; 23(1):ii-iii.
61. Mertes H, Pennings G (2009). Ethical aspects of the use of stem cell derived gametes for reproduction.
    Health Care Anal. Epub, Oct 7
62. Meyer MN, Fossett JW (2009). The more things change: the new NIH Guidelines on human stem cell
    research. Kennedy Institute of Ethics Journal;19(3):289-307
63. Myser C (2008). Ethnographic insights regarding the "social role" and "moral status" of the fetus as
    "patient": comparing developed (United States & Sweden) and developing (India) countries. American
    Journal of Bioethics; 8(7):50-2, discussion W4-6
64. Newell C (2006). Disability, bioethics, and rejected knowledge. The Journal of Medicine and
    Philosophy; 31(3):269-83
65. Niemelä J (2010). What put the 'yuck' in the yuck factor? Bioethics, Epub Feb 25.
66. Nikolaos M (2008). The Greek Orthodox position on the ethics of assisted reproduction. Reproductive
    Biomedicine Online;17 Suppl 3:25-33
67. Pellegrino ED (1987). Ethics. JAMA; 258(16):2298-300
68. Pellerin D (2002). Stem cells and cell therapy. Contribution to the ethical debate. Comptes Rendus
    Biologies; 325(10):1059-63
69. Pennings G. (2007). Decision-making authority of patients and fertility specialists in Belgian law.
    Reproductive Biomed Online; 15(1):19-23.
70. Pennings G, de Wert G, Shenfield F, et al (2008). ESHRE task force on ethics and law 15: cross-
    border reproductive care. Human Reproduction; 23(10):2182-4
71. Revel M (2003). Human reproductive cloning, embryo stem cells and germline gene intervention: an
    Israeli perspective. Medicine and Law; 22(4):701-32
72. Rosenthal MS (2010). A preventive ethics approach to IVF in the age of octuplets. Fertility and
    Sterility; 93(2):339-40.
73. Rothman BK (1985). The products of conception: the social context of reproductive choices. Journal of
    Medical Ethics; 11(4):188-95
74. Sahinoglu-Pelin S (2002). Artificial reproductive technologies (ART) applications in Turkey as viewed
    by feminists. Human Reproduction and Genetic Ethics; 8(1):7-10
75. Samtani B S, Jadue Z M, Beca I JP (2009). How does Hinduism analyze an ethical clinical dilemma.
    Revista Medica de Chile; 137(11):1511-5.
76. Schenker JG (2000). Women's reproductive health: monotheistic religious perspectives. International
    Journal of Gynecology and Obstetrics; 70(1):77-86
77. Seavilleklein V (2009). Challenging the rhetoric of choice in prenatal screening. Bioethics; 23(1):68-77
78. Shenfield F, Pennings G, Cohen J, et al (2005). ESHRE Task Force on Ethics and Law 10: surrogacy.
                                              Page 18 of 18

    Human Reproduction; 20(10):2705-7
79. Shenfield F (2005). Semantics and ethics of human embryonic stem-cell research. Lancet;
80. Sills ES, Healy CM (2008). Building Irish families through surrogacy: medical and judicial issues for
    the advanced reproductive technologies. Reproductive Health 4; 5:9
81. Steinbock B (1995). A philosopher looks at assisted reproduction. Journal of Assisted Reproduction and
    Genetics; 12(8):543-51
82. Strong C (2005). Harming by conceiving: a review of misconceptions and a new analysis. Journal of
    Medicine and Philosophy; 30(5):491-516
83. Su B, Macer DR (2005). A sense of autonomy is preserved under Chinese reproductive policies. New
    Genetics and Society; 24(1):15-29
84. Taymor K, Scott CT (2009). The practical consequences of a national human embryonic stem cell
    registry. Stem Cell Reviews; 5(4):315-8
85. Timpson J(1996). Abortion: the antithesis of womanhood? Journal of Advanced Nursing; 23(4):776-85
86. Turner L (2009). Does bioethics exist? Journal of Medical Ethics; 35(12):778-80
87. Ueda N, Kushi N, Nakatsuka M, et al (2008). Study of views on posthumous reproduction, focusing on
    its relation with views on family and religion in modern Japan. Acta Medica Okayama; 62(5):285-96
88. de Wachter MA (2004). Ethical aspects of cryobiology: responsible applications in biomedicine and in
    clinical practice. Cryobiology; 48(2):205-13
89. Walters L (1986). Ethical issues in intrauterine diagnosis and therapy. Fetal Therapy; 1(1):32-7.
90. Warnock M (1987). 'The good of the child'. Bioethics; 1(2):141-55
91. White BD, Zaner RM, Bliton MJ, et al (1993). An account of the usefulness of a pilot clinical ethics
    program at a community hospital. QRB: Qualitative Review Bulletin; 19(1):17-24.
92. White BD, Zaner RM. (1993). Clinical ethics training for staff physicians: designing and evaluating a
    model program. The Journal of Clinical Ethics; 4(3):229-35
93. Wolf SM, Gupta R, Kohlhepp P (2009). Gene therapy oversight: lessons for nanobiotechnology. The
    Journal of Law, Medicine, and Ethics; 37(4):659-84
94. Woodcock S (2010). Abortion counseling and the informed consent dilemma. Bioethics. Epub, Feb 3.
95. Zahedi F, Larijani B (2008). National bioethical legislation and guidelines for biomedical research in
    the Islamic Republic of Iran. Bulletin of the World Health Organization; 86(8):630-4
96. Zoloth L, Backhus L, Woodruff T (2008). Waiting to be born: the ethical implications of the
    generation of "NUBorn" and "NUAge" mice from pre-pubertal ovarian tissue. The American Journal of
    Bioethics; 8(6):21-9

Description: What is new in reproductive health ethics? A lot, but not enough. Ethical principles of public health are distinguishable from principles applied in modern bioethics. At the risk of over-simplifying the difference between clinical ethics and public health ethics, it could be said that the default position of clinical ethics centers on respect for the individual patient and his/her autonomy, whereas the default position of public health ethics centers on the pursuit of thecollective or common good. In other words, ethics in medical practice and research operates as a gatekeeper between what is legal, and what is not. Admitting and understaning ethical codes by both patient and provider, may reduce court-visited and ordered medical interventions.